Sleep Like A Baby? What Does That Really Mean? (In Vermont)

1. Sleep Like A Baby? What Does That Really Mean? (In Vermont) James J. McKenna Ph.D Edmund P.Joyce C.S.C. Chair in Anthropology..Director, Mother-Baby Behavioral Sleep Laboratory University of Notre Dame du Lac

2. How and in what ways has culture by way of social values and goals mediated and influenced not only the study and conceptualizing of infant sleep i.e. proper positioning, arrangement, nighttime feeding patterns, and appropriate parental responses but the biology of both maternal and infant sleep in complex urban western settings? Why do 20-40% of western babies have “sleep problems to solve”? What is “normal, healthy infant sleep”Do we answer from a biological or recent cultural point of view? Does it matter? If so, How?

3. 1.Disarticulated from mother… No touch; No smells; No sounds No movement; No body heat’ No breadth exchange

4. Fact: The only object/surface/entity on or around which the baby is “designed” to sleep remains the mother’s body.

5. “There is no such thing as a baby, there is a baby and someone.” D.Winnicott

6. ...in our enthusiasm to view the human infant (culturally) as a separable, autonomous organism, we have pushed too far the concept of the infant’s physiological independence from the parent…confusing the infant’s preparedness to adapt, with actual adaptation… confusing the infant’s abilities to sleep alone with moral and scientific truths and meanings

7. Hierarchy of value is imposed: • On moral grounds… • the “good” baby vs. the “bad” baby, • but also, the effective /strong parent vs. the ineffective/weak parent; • On scientific grounds… • The developmentally superior, competent baby vs. the inferior, less competent (spoiled/indulged) baby

8. Limitations of Western Pediatric Sleep and SIDS Research adult- centric; non-evolutionary; ethnocentric; (a)theoretical (no theory around which to interpret clinical events or research results) Who is the infant? What do infants need? What criteria should be used to decide, that is... dominant cultural practices? biological? species-wide? local? Western reductionist science methods have not served infants well.. Eliminated concept of “the mother-infant dyad” as the unit of analysis

9. Western pediatric medicine suffers from what Professor George Williams calls…the “fallacy of medical normalcy..” if we do it, or practice it, or value it (in western society)..it must be right and/or appropriate

12. Interacting factors-- (most and least relevant ?) From: Sally Baddock (New Zealand) Peter Blair and Helen Ball (Great Britain), Caroline McQuillan (Australia) James McKenna and Lane Volpe (USA) Cultural least relevant Where babies actually sleep Scientific Public Health Family including economic status Infant and Parental Biology Including Feeding Method most relevant

13. “It’s not what we know that gets us into trouble….it’s what we know…that just ain’t so! From: Everybody’s Friend (1874) By Mark Twain

14. ….culturally favored child care practices change independent of, and much faster than, infant biology…. (ideologies or goals that underlie recommendations are often historical and ideological in origin but passed off as, if not confused for, scientific findings)

15. In the west solitary sleeping arrangements became entangled with, and one and the same with, “good” morals if...sleeping alone through the night is medically “good” for babies then don’t “good” babies do so, and “good parents” enforce it?

16. Cascading Inter-connections Regarding Western Parent-infant Sleep Conflicts • (Infants rarely have sleep problems, parents do..!) • Western parents suffer from a variety of damaging diseases not the least of which is.. the disease of false and unrealistic expectations..a cultural and not a biological model of infant’s sleep patterns; • the disease of confusing parental desires and wishes and “best interest” with that of their infants • the “die”model of sleep--the only “good” sleep is an uninterrupted one; • that infant sleep behavior correlates with good moral character, and general future social skills and competencies…in domains other than sleep; • the presumption of an adversarial relationship existing between infants and parents as regards sleep..Consider the book title: “Winning Bedtime Sleep Battles”..and “Babywise” ;

17. Why Our Babies “Can’t” Sleep and Why Western Parents Are the Most Exhausted And Disappointed Parents In The World • suffer from the disease of misinformed expectations • devoid of the “relational” familial factors (where baby sleeps and feeds as regards parental emotions and goals;) • devoid of intrinsic (infant) factors (temperament, personality , sensitivities); • categorizes infant’s inability to follow cultural model as…”disease”, sleep disorder, immaturity, and, thus, infant becomes a “patient”; • promotes one- size- should- fit- all; • promotes one sleeping arrangement as a moral issue and gives it a specific set of inappropriate meanings;

18. Why Do Parents Have Infant Sleep Problems To Solve? • Because no two people in any relationship have exactly the same “best’ interests..always trade-offs are involved…sleep is relational..not medical • current one-size- must- fit- all model devoid of relational-emotional aspects including unique infant “intrinsic” factors • such as infant sleep personality-temperament and how these articulate with unique needs of parents to respond to perceived infant needs, as well as the parents own needs for contact with their infants; • Current models either ignore altogether the critical relationship between nighttime breastfeeding and sleep, or minimize its significance to infant-maternal health.. seeing breastfeeding as a threat and not added value • wish nighttime feeding would just go away as it threatens the priority given to consolidated sleep (the predominant cultural value) • Transition away from thinking of co-sleeping as pathology (psychology) to dangerous (medical)

19. Until recent, western historic periods, no human parents ever asked: Where will my baby sleep, how will I lay my baby down to sleep, and how will I feed my baby? most human parents still don’t!

20. For the human infant the three functionally inter-related (adaptive) components of normal, healthy infant sleep include: • Sleep location • (next to mother for social or co-sleeping behavior involving on-going sensory exchanges, monitoring and mutual regulation) • Nighttime feeding • exclusive breast feeding • Sleep position • Back (supine)

21. The cultural-medical dismantling of this biological system led to the deaths of thousands of western infants from, SIDS, accidental asphyxiations and/or other SUDI(i.e.from social sleep …to solitary infant sleep--from breast feeding …to bottle-formula feeding from supine …to prone infant sleep position

22. THE UNDERMINING OF MATERNAL CONFIDENCE AND KNOWLEDGEBenjamin Spock wrote to mothers in: Baby Care “You know more than you think you do…. don’t be afraid to trust your common sense. Bringing up baby won’t be a complicated job if you take it easy, trust your own instincts,and follow the directions your doctor gives you! cited by tina thenevin,1993, mothering and fathering

23. Decision -making hierarchy is distributed--physician at top, lactation consultant, nurses, parents at bottom; “the power of authoritative knowledge is not that it is correct but that it counts” “Standard Care” enforced by legal and institutional actions; Examples: prosecution of Salt Lake City couple whose infant died after co-sleeping (child abuse homicide); or lactation consultants fired if they give safety information on bedsharing. Invalidates other knowledge systems; Parental knowledge counts for nothing Parents must override instincts- as medical personnel always know best; To understand current debate/discourse over sleep must understand Bridget Jordan’s delineation of the place of “authoritative medical knowledge” in our western culture. Modified from: Birth In Four Cultures by Bridget Jordan

24. Authoritative medical knowledge… “…to legitimize one way of knowing as “authoritative” devalues, often totally dismisses, all other ways of knowing. Those who reject authoritative knowledge systems tend to be seen as backward, ignorant, or naïve troublemakers…”

25. Socio-cultural and Historical Factors and Forces Leading to Erroneous Scientific Understandings (Undermining Parental Confidences and Empowerment) • rise of child care experts using moral judgments as a basis of recommending what infants “need’..what is worth “investing in” as a practice.. • belief in superiority of technology, rather than on maternal bodies to stimulate, hold and nurture; • emphasis on “average expectable population outcomes” rather than on individual variability or potential.. per any given behavioral parenting strategy; • emphasis on ethnocentric social values and ideologies (not biology) to guide research and conclusions..”fallacy of medical normalcy” (GWilliams) • improper medicalization of relational (caregiving) issues ..assumed to be best understood by pediatricians (who generally have no training in human social development or human evolution… • “Pathologizing” of normal behavior (crying when left alone) ..making infants into patients (blaming the victim for the crime) in need of correction when they fail to follow cultural scripts..”Never let a baby fall asleep at the breast” AAP Guidelines For Infant Sleep • social constructions of infancy, not /biological- evolutionary based (influences of Freud, Klein, Watson..psychology in general); • “Science” of infant feeding (bottle-formula feeding) and sleep pediatrics became one and the same with… mutually reinforcing moral ideas about who infant should be, or become, rather than who they are…and how husbands and wives should relate vis a vis distance, authority and separation from children…also, ideologies about the bedroom as a “sexual place..”

27. The Complex History of Infant Sleeping Arrangements In Western Industrial Societies Is Reduced To Simple Understandings Congruent With Present Cultural Beliefs: • inevitable suffocation/overlying/SIDS • inevitable psychic damage to infant • inevitable rupture to conjugal (husband/wife) relationship • inevitable prolonged dependency of infant/ child • inevitable lack of autonomy in infant/child • NOTE: not one controlled scientific study documents the benefits of solitary infant sleep, or the alleged deleterious social/psychological/physiological consequences of safe cosleeping with breast feeding

28. How A Folk Myth (normal, healthy babies sleep alone) Achieved Scientific Validation #1: Initial test condition—infant sleeps alone, is bottle fed, and has little or no parental contact #5: To produce “healthy” infant sleep, replicatethe test condition “Scientific” validation of solitary infant sleep as “normal” and “healthy” #2: Derive measurements of infant sleep under these conditions #4: Publish clinical model on what constitutes desirable, healthy infant sleep. #3: Repeat measurements across ages, creating an “infant sleep model”

30. Changing perceptions….of what’s good for baby…“The constant handling of an infant is not good for him. The less he is lifted, held and passed from one pair of hands to another, the better, as while he is young his bones are soft and constant handling does not tend to improve their development nor the shapeliness of his little body. the newborn infant should spend the greater portion of his life on the bed” FROM: THE BABY MARIANNA WHEELER 1901 HARPER BROS: NEW YPRK LONDON

31. CHANGING PERCEPTIONS OF WHAT INFANTS NEED... THE MOTHERHOOD BOOK (1935) “Babies should be trained from their earliest days to sleep regularly and should never be woken in the night for feeding….” “Baby should be given his own bedroom from the very beginning. he should never be brought into the living room at night”

32. Richard Ferber, M.D. Director, Center for Pediatric Sleep Disorders, Children’s Hospital, Boston slide courtesy of Meret Keller and Wendy Goldberg

34. Dr. Richard Ferber “changes his mind”..?? But the larger and more important question is…What is it about our culture that makes us care, or makes it important what someone who has no familiarity with our baby or our family thinks about this very personal issue? • “If you find that you actually prefer to to sleep with your baby you should consider your own feelings very carefully”. • “Whatever you want to do , whatever you feel comfortable doing, is the right thing to do, as longs as it works….. most problems can be solved regardless of the philosophical approach chosen” (Ferber: 2006: 41) 1976 2006

35. Changing concepts related to where babies can or should sleep..the beat goes on… (1976, 1999)“…Sleeping in your bed can make an infant confused and anxious rather than relaxed and reassured. Even a toddler may find this repeated experience overly stimulating”(2006) “Children do not grow up insecure just because they sleep alone or with other siblings, away from their parents; and they are not prevented from learning to separate, or from developing their own sense of individuality simply because they sleep with their parents” (Ferber 2006:41).

36. “Sleeping With Baby: An Internet -based Sampling of Parental Experiences, Choices, Perceptions, and Interpretations In A Western Industrialized ContextJ.J. McKenna and L.E. Volpe in press Inf. Child Dev. Based on self-selected sample of 200 mostly middle class mothers from Canada, United States, Australia, and Great Britain…. 400 pages of narrative “ethno histories” in response to nine questions…

37. “Sleeping With Baby: An Internet -based Sampling of Parental Experiences, Choices, Perceptions, and Interpretations In A Western Industrialized Context” • How did you, do you, co-sleep? • How long did you/have you co-slept? • Why are you co sleeping, or, why did you co-sleep? • If you already have children who moved on from co-sleeping, what do you think of your experience? • If you are still co-sleeping, what do you think of it now (i.e. as opposed to your attitude when you began? • How well do your children sleep now? • Are you breast feeding or did you breast feed? If so, for how long? • Do you and/or your partner smoke? • By co-sleeping, do you think you ever saved your child’s life? • questions originally posted on

38. Recurrent parental themes • awareness of comments concerning “warnings” against bedsharing and knowledge of bedsharing risks; • relationship between breast feeding and bedsharing; • emotional bases of and correlates to co-sleeping for mothers (parents) and infants alike; • transition to separate beds; • co-sleeping and effects on child’s socio-emotional development; • potential life saving experiences

39. ON RESPONDING TO INFANT CRIES... “A RAPID AND SYMPATHETIC RESPONSE TO OUR BABIES CRIES IS THE FOUNDATION OF STRONG FAMILY VALUES, NOT THE UNDERMINING OF THEM”... FROM: HARVEY KARP…HAPPIEST BABY ON THE BLOCK (2002)

41. Ahhh… The question of promoting infant “independence”(three questions) what exactly is “independence for a 2-3 month old infant? does it really correlate with solitary infant sleep practices? is “independence of children” what parents really want?

42. But, is “independence” really best in the long run.. that is, is “independence” from parental intervention at 13 or 14 years of age as desirable as it is, say, at 2 months? Does sleeping alone actually correlate with autonomy, competence, and/or confidence, or happiness or to any other desirable personality attribute not obtainable through some other arrangement or other childhood socialization experiences?

43. According to Daniel Stern (1985) • “..the emotionally disturbed patient is one whose early experiences lacked attunement…..the tracking and attuning--which permits one person to be with another in the sense of sharing likely inner experience on an almost continuous basis”

44. When dependence IS autonomy “Autonomy in the sense of psychotherapy, implies taking control of one’s life…emotional autonomy does not mean isolation or avoidance of dependency. On the contrary, the lonely schizoid individual who preserves his “independence” at all cots may well be in a state of emotional heteronomy, unable to bear closeness with another person because of inner dread and confusion.

45. dependency AS autonomy A similar state of emotional heteronomy affects the psycho- path who is unaware of the feelings of others. The emotionally autonomous individual does not suppress her feelings, including the need for dependence, but takes cognizance of them, ruling rather than being ruled by them” (Homes and Lindley 1989)* * The Value of Psychotherapy (1991) J.Holmes and R.Lindley. Oxford University Press

46. Crying

47. Chimps have…. ..bad days, too!

48. Recent cultural ideologies place BOTH infants and parents at odds with their biology (emotions) • Western Caregiving: • Child is not in contact with mother most of the time (crib, stroller) • Baby is kept supine • Scheduled separated feedings • Social pressures not to respond to infant crying for fear of “spoiling” • Separation, minimal feedings, is thought to be “good for baby”

49. Function of Crying • primary form of pre-verbal communication; • evolved maximize chances of infant survival and parental reproductive success. • signals infant distress, fear, hunger, pain and/or discomfort.. • crying ensures proximity to parent, protection from predators.. (Bowlby) • Though crying is not the normal way by which infants receive breast milk…crying is a late sign of infant hunger signals …

50. Evolutionary Adaptedness • “A number of studies in human infants have confirmed the potential importance of both contact and nutrients as regulators of infant behavioral state…increasing carrying from 3 to more than 4 hours a day reduces duration…of crying/fussing behavior by 43% at 6 weeks of age” (41).